Category: health

duterte, pemberton, HIV-AIDS

it was the first time i’d ever heard digong duterte speaking lengthily on anything, so i was totally unprepared for all of it.  yes, the puntanginas and other cuatro letras and the libog and bathroom and bayag talk  shocked me at first, pero sabay halakhak everytime.  i think i forgave him very quickly for the ‘tanginas because, well, he was cursing mostly at stuff i have myself cursed at in private (except for the pope), and it was somewhat cathartic, haha.

but beyond the oral ejaculations he was talking a lot of sense, he knows, he has lived, mindanao history, and is rightfully pissed off at imperial manila and whoever made a fish out of moro hero lapulapu LOL.  however, the sex talk and the going-to-confession and related stories were not as easy to forgive, napaka-for-adults-only, what if the kids are listening?  my nanay was very old school.

the very next day, as i was listening to the olongapo judge’s ruling on the killing of sex worker jennifer laude by US marine scott pemberton  — JUNK EDCA! — and hearing more sex talk, if on a different plane and in a different language from duterte’s — fuck, oral sex, blow, penis, vagina — the synchronocity struck me, and the thought occurred that this could be a good thing.  the start of a process of desensitization to sex talk, because we NEED to talk about sex.  real sex education, in the vernacular, is the only way we can stop HIV-AIDS from spreading and becoming full-blown.

PHILIPPINE HIV EPIDEMIC UPDATE (2015)
UN AIDS

The rapid rise in HIV infections nationwide, with some 21 new cases reported every day per DOH records4, has made the Philippines one of only a handful of countries at risk of a full-blown AIDS epidemic if it is unable to address the problem on time. The 646 new cases reported last February is the highest number since the Philippines’ first case in 1984, according to the DOH. The numbers in six cities — Quezon City, Manila, Caloocan, Cebu, Davao and Cagayan de Oro—already exceed the national prevalence rate of 3.5 percent4. While HIV is spread primarily through unsafe sexual contact, it can also be contracted through the sharing of dirty needles during drug use.

Increasing prevalence in key populations. National HIV prevalence remains under 0.1%, but rapidly expanding among key affected populations (KAP)2. By 2013, HIV prevalence reached 5% to 8% among males who have sex with males (MSM) in the cities of Cebu, Quezon and Manila; 53% among people who inject drugs (PWID) and 5% among female sex workers (FSW) in Cebu City1.

More are infected. The number of cases reported has shown a steep increase in the recent years – from less than 1 case a day in 2006 to 21 cases a day by March 20151. The actual cases are estimated to be at least double of those reported. The Philippine National AIDS Council (PNAC) has projected that the total number of HIV cases in the Philippines could reach 37,000 [as high as 54,000] by 20152. 12,000 of those will be needing treatment2 which could cost the Philippine Health Insurance around P360 million ($8.4 million).

Those infected are young with a median age of 27. HIV infection among 15-24 years old increased more-than ten-fold, from 44 in 2006 to 995 in 20151. The period of initiation to sex and drug use among key affected populations is as early as from 14 years old2.

Male to male transmission had significantly increased. Sex is still the main mode of transmission with, 85% of new cases were reportedly through male-to-male sex in 20151.

More local transmission. HIV cases among Overseas Filipino Workers (OFW) continue to increase (395 cases in 2013 – highest ever) despite the decrease in proportion of OFW to the total cases from 42% in 2006 to 11% in 2013 indicating that local transmission has outpaced infections reportedly contracted overseas.1

Very Low Prevention Coverage mostly below national targets of 80% since 2005; specifically 63% for establishment-based Female Sex Workers, 38% for freelance FSW, 23% for Males Who Have Sex wth Males (MSM) and 11% among people who inject drugs (PWID). Low number of Key Affected Persons (KAP) are tested for HIV (merely 14%) and zero for key affected populations under the age of 18.

High-risk practices among KAP continues. Knowledge levels (index of basic HIV knowledge including misconceptions) among Key Affected Persons was only 32%, with those aged 15 to 17 years, even lower.

basic HIV knowledge, including misconceptions, of gay and bisexuals, female sex workers, needle-using druggies, is only 32%, and even lower than that for teen-agers.  sa madaling salita, kulang na kulang ang sex education.  the departments of education and of health will, of course, claim that all students get sex education, but the question is, what kind?

In a recent media forum, people living with HIV (PLHIV) advocate Wanggo Gallaga said there is an immediate need for schools to include sex education modules in order to encourage those with risky sexual behaviors to practice safe sex.

“What we have to do is to educate people properly. It has to start earlier. When it comes to health, education is very shallow. Biology lang ang tinuturo sa schools e. We don’t talk about consequences of sex,” said Gallaga. 

yes.  it’s not enough to teach about reproductive body parts and how babies are made.  kailangan din ituro ang tungkol sa libog and hormones, vaginal and anal sex, and the consequences of unprotected sex, besides unwanted pregnancies, as in sexually transmitted diseases, the worst of which is human immunodeficiency virus (HIV) infection that untreated leads to the painfully deadly Acquired Immunodeficiency Syndrome (AIDS).

most important, these teaching modules should be not only in english but also in tagalog and taglish, and gayspeak na rin, as well as in the dialects of target audiences, which should include young and old, male and female, gay and bisexual, specially the sexually active who engage in casual sex / exchange bodily fluids with different partners.

read godofredo u. stuart’s Sex Education: The Comic Failure of Language and marlon james sales’ Sex and the Missionary Position: The Grammar of Philippine Colonial Sexualities as a Locus of Translation.

sex education is key to preventing an HIV-AIDS epidemic.  government agencies (DEPED and DOH) simply have to get on the job, the sooner the better.  for certain the bishops will raise a howl.  let them.  it might even be a good sign that all they’re apoplectic about right now is the cursing at the pope, the adultery committed with two wives and two girlfriends, and the allegation of sexual abuse by jesuits.  i haven’t heard anyone decrying the bayag and libog talk.  maybe they can’t find the words.  while we have all the words we need.

*

772 cases of HIV/AIDS recorded in June, the highest ever in one month – DOH
Living with HIV in the Philippines
The Predictable Failure of HIV/AIDS Education in the Philippines

And now for Ona. . . A Manila Trial a la Nuremberg?

By G. U. Stuart, MD

I thought the controversy on the ActRx Triact anti-dengue drug was going to die a quiet death—consigned to inevitable oblivion by the strong arm of politics that threatened many close to the heart of the research, nitpicked every which way, vilified as crap, with a media ensemble so eager to chorus their tsutsuwariwaps, amens and hallelujahs for the rantings of the powers that be.

But, perhaps, the controversy is far from dead. There has been a flurry of emails from the other side of the controversy—taking Garin, Claudio, and Leachon to task.

But now, a new voice from the anti-Ona trenches—Dr. Francisco Tranquilino, a regent of the Philippine College of Physicians Board and Assistant to the dean and college secretary of the UP College of Medicine. He sings the familiar line: the ActRx Triact dengue study was “technically and ethically fatally flawed.”

Dr Tranquilino draws on the  Declaration of Helsinki-Ethical Principles for Medical Research Involving Human Subjects.  He criticizes the inclusion of children in the Triact study as a “vulnerable” group. But how can you exclude children in a drug study for a disease where the children population is most vulnerable, where the majority of deaths happen in the same population. Also, nowhere in the Helsinki Declaration is it stated that children should be excluded in all studies. In fact, article 20 states: Medical research with a vulnerable group is only justified if the research is responsive to the health needs or priorities of this group and the research cannot be carried out in a non-vulnerable group. In addition, this group should stand to benefit from the knowledge, practices or interventions that result from the research. The article, in essence, supports the study of the drug in this vulnerable group of patients.

And again, to belabor what has been said so many times, artemisinin has been extensively studied and used in  thousands of children and has proven to have an excellent safety profile.

Not done with bully pulpit pronouncements, Dr. Tranquilino draws from history and says: “Like the Nuremberg Trial, we might need out own Manila Trial” —referring to a series of trials for the prosecution of prominent members of the political, military, and economic leadership of Nazi Germany in the 1940s. Is he insinuating an analogy with the “Doctors’ Trial” brought about by Nazi human experimentations that led to the development of the Nuremberg Code of medical ethics?

A Manila Trial akin to  the Nuremberg Trial? Are the doctors being accused of crimes against humanity? Is their research work being compared to Nazi human experimentation? That is a grievous, malicious, odious and defamatory insinuation—an insult to the Philippine medical research community. It demands an apology.

It also calls upon the community of physicians—researchers and clinicians alike—to show visible and audible umbrage. Till now, there have been only emails expressing quiet dissent, decrying the dirty and brutal politics that reigned in the Ona ouster and termination of the Actrx Triact anti-dengue drug study. To continue with silence is to risk consigning future medical research to the control of politics and politicians—to its inevitable demise or awful compromise.

And to Dr. Anthony Leachon, president of the Philippine College of Physicians: Do you agree with this position and insinuation by Dr. Tranquilino? And, lastly, let me rephrase your quote : “The interest of patients should take precedence over the interest of science.” I posit: The interest of patients should take over the interest of politics.

disgraceful discourse on the anti-dengue drug

i get asked why i bother to blog again and again on ActRx TriAct when no one seems to be reading, much less agreeing; mostly, the comments only echo, insist on, what kill-the-cocktail proponents feed an unthinking mediocre media.

meron naman akong readers, heh, or so my site stats tell me, and dr. stuart and i have been receiving email thanking us for the posts and the research and wishing that mainstream media would pick them up, publish them as well, so the public may know.  yeah, we wish.

but even if i had just a handful of readers, or even if no one agreed with the sentiments expressed herein, i would continue to blog, if only for the record.  i would continue to share my thoughts and reactions on an issue such as this that has national and worldwide significance.  dengue is a global public health concern, after all, and let it not be said, now and in the future, that pinoys, one and all, sat back and allowed the killing of a promising anti-dengue cocktail without question or resistance.

which is also to say that it is dismaying, nay, disturbing, nay, scandalizing! that the public discourse is so one-sided.  except for dr. tony leachon, speaking for the philippine college of physicians and the philippine medical association, and dr. sylvia claudio in her online column – both pro-garin, it would seem — we are not hearing any dissent from the medical community.  no doubt there are dissenters, but unfortunately they choose to not make public their informed opinions (along with their identities), they choose to not engage in, contribute to, an exchange of  expert views, whether for or against.  ask them why, and they’ll invoke the politics, the dirty politics; they’d rather not get involved.

but surely the good doctors know that their silence has political repercussions, too, giving the impression that they’re all okay (as in, all right) with acting DOH sec garin’s godawful decision to stop the ActRx TriAct clinical trials?

yeah, the devil is in the politics.*  and on this blog, we dare confront that devil.

Dr. Stuart:  I received anonymous emails with links to articles on the position of the Philippine Medical Association (PMA) and the Philippine College of Physicians (PCP), in support of the cancellation of the expanded clinical trials of the anti-dengue drug, ActRx TriAct. One was accompanied by a link to the WMA (World Medical Association)’s Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects.

What the media reported on the PMA POSITION was a nitpicking criticism, full of text extracts from Dr. Calimag, without even the briefest elucidation on the censured design and analysis flaws.

In contrast, The WMA DECLARATION OF HELSINKI: ETHICAL PRINCIPLES FOR MEDICAL REASEARCH INVOLVING HUMAN SUBJECTS was an interesting read. I wondered which of the 37 articles the ActRx TriAct study violated. I likewise wondered if maybe it was sent in support of the ActRx TriAct study.

The last article was especially compelling: Unproven Interventions in Clinical Practice — “…where proven interventions do not exist or other known interventions have been ineffective, the physician, after seeking expert advice, with informed consent from the patient or a legal representative, MAY USE AN UNPROVEN INTERVENTION IF IN THE PHYSICAN’S JUDGMENT IT OFFERS HOPE OF SAVING LIFE, RE-ESTABLISHING HEALTH OR ALLEVIATING SUFFERING.” Compelling — because it advocates the use of the medicine for compassionate use.

I don’t want to belabor the fact. The components of the ActRx TriAct anti-dengue therapy are old drugs, being repurposed or repositioned for new uses. Repositioning or repurposing drugs is one way of significantly shortening the process of drug studies and trials. Yet, criticisms continue to express incredulity on why the ActRx TriAct therapy did not take the usual 12 to 14 years of new drug development.

The PCP POSITION also slammed the people behind the clinical trial for including some children as subjects. Why are doctors so horrified or against testing the efficacy of the treatment on children? Ladies and gentlemen, it is the children who are most vulnerable, it is in the children’s sector where most fatalities are found in a 2011 study. From January to September, there were a total of 86,662 cases, with 65,000 (74%) occurring in all confirmed cases. 36% of these occurred in children aged 1-9 years, resulting in 265 deaths, representing 60% of deaths due to dengue in 2011.

CRAP?  There was also a public status on facebook posted by Dr. Claudio, that “the science supporting Ona’s anti-dengue miracle drug is crap.” In the course of public discourse, that the best argument a doctor in her position can offer is that the study is “crap,” is sad, unprofessional, disreputable, and downright juvenile. The study is crap!—and that’s it? We take her word for it? We deserve better than that. She should not have called a study “crap” based on reports she is privy to but she is not willing to divulge. Such criticism is crappier than crap.

The medical voices or the guardians of truth charged with informing the public is burdened with the responsibility of providing explanatory answers, not silently agreeing to pronouncements of “crap.”

We need a clear judgment and resolution on this controversial matter from a really independent scientific review board — if that is at all possible — not rantings from the bully pulpit or DOH press releases dutifully published by kowtowing media, repeating, ad nauseam, pronouncements from on high without looking deeper into or researching the issues.

GAME OVER?  But is it all moot now? Has the circus left town? Dr. Ona has resigned, silenced, lips politically zipped? The pneumonia vaccine issue abandoned to die a quiet death? The anti-dengue drug vilified as crap? The study criticized as unethical, diagnostically inaccurate, no endorsements, dubious paper trails, poorly designed, flawed data analysis, blah blah blah? Were these a fagot of separate political issues—of demolition, positioning, wheeling-dealing, and a clashing of government egos—really meant to get Ona out of the picture?

Or is this partly issuing from the great disdain by many in the medical community of anything that has to do with alternative medicine? Remember, many of the medicines that grace the pharmaceutical landscape are plant derived, and many more are waiting to be discovered, many a lot safer, without the toxicities of synthetic pharmaceuticals.

In the ActRx TriAct study of 290 patients — 145 received the drug treatment, 145 did not — there were no deaths in both groups of patients. The PCP concludes that because no one died in the 145 who didn’t take the drug, the “experimental drug added nothing in preventing deaths.” This is a valid scientific conclusion? Or just a position intent on seeing the cup half empty rather than half full.

In different studies, dengue deaths ranged from one for every 185 to 250 cases. In the ActRx TriAct study of 290 patients (145 with treatment, 145 without), taking the optimist position, the absence of death might suggest the benefit of prevention of at least one fatality.

Calimag also said: “the lack of adverse events in a small sample size is not conclusive evidence of the absence of harm.” Taking the optimist position, the absence of adverse effects might suggest the absence of toxicity — three drug components that have already undergone extensive toxicity evaluation — and the absence of deaths, albeit a small sample size, should support further expanded study and testing, especially in the many provinces that have attained malaria-free status.

THE CAT IS OUT OF THE BAG.  Even here in the boondocks, a local alternative healer has asked me about it. In places like these, what is to keep the local healers from accessing the separate components of the drugs for the occasional desperate families seeking any possible treatment for dengue stricken family members?

Is the study dead? I hope not—because the anti-dengue drug treatment has NOT been debunked. And calling it “crap” doesn’t kill it. Perhaps, dissenting voices from the medical community might still surface and dare to disagree with the powers that be, provide a badly needed and audible point of view.

If it is a bad study, tweaked or falsified, or in the end, proven as crap, I’ll be glad to help pull the trigger and kill it. BUT if the potential to save lives still exists, the testing and expanded use must be allowed to go forward. This year, from January to September 2014, there have been about 60,000 reported cases of dengue in the Philippines, with about 242 deaths (4 deaths for every 1,000 cases). These numbers cry out.

What a shame if in the end ActRx TriAct is taken elsewhere, and the drug is shown to work.

my pet theory is, the demolition job on ona and ActRx TriAct is in aid of that dengue vaccine for which a huge pharmaceutical company has spent $1.5 B on research and development, soon to be out in the market.  as i’ve blogged before, we could use both ActRx TriAct AND a dengue vaccine.  dr. stuart tells of the vaccine’s limitations here.

and if you’ve read this far, good for you, i saved some juicy tidbits for last.  over the holidays, different grapevines were buzzing with anti-garin stories: how she wants the post so badly, sorry na lang si ona, and how she’s not even qualified for such a high post — she’s more a politician daw than a physician, much less, a scientist (check out her wikipedia profile).

but the juiciest story, a sweet stab of sarcasm from ona himself, came via inquirer’s christmas day report, Ona: Loss of Aquino’s confidence prompted me to quit

When asked about his relationship with the acting health secretary, Ona said he thought it was “very ideal.’’

… “My personal things were brought to my house even before I officially announced my resignation and there’s only one person in DOH who could make such order,’’ Ona said.

whew, what a game she plays.  this is the same aquino-appointed acting DOH sec who brazenly disobeyed the quarantine rules imposed on families of travellers from ebola-stricken countries, the very same one, still unmasked, whom our senators welcomed to their august halls with beso-besos to boot.

the anarchy proceeds apace.  in the highest places yet.

*

* “The devil is in the politics” is how i ended the book Revolutionary Routes: Five stories of incarceration, exile, murder, and betrayal in Tayabas province, 1891-1980 (2011)

So who wants Dr. Ona’s post?

By Katrina S.S.

Second of two parts

Clinical trials and the anti-dengue cocktail

But the bigger story is about the anti-dengue cocktail that is ActRx Triact, the clinical trials for which were started in 2012, as ordered by Dr. Ona. Acting Health Secretary Janette Garin stopped the clinical trials the moment she stepped in, declaring that it had “no legal basis” as it had yet to be approved by the Food and Drug Administration (FDA). At that point the Philippine Council for Health Research and Development (PCHRD) had questioned the soundness of the science behind the clinical trials. Since then the Philippine Medical Association (PMA), the Philippine Society for Microbiology and Infectious Diseases (PSMID), and members of the Philippine College of Physicians (PCP) have thrown their support behind Garin’s decision to stop the trials. These organizations question the science and ethics behind the clinical trials, and assert the dangers it poses to the public’s health. Dr. Sylvia Claudio has called the science behind the clinical trials “crap,” saying that it is “a medical horror story.”

Read on…